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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# �.o REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 41,3113 <br /> TO yU ,TAM WTh P&i F I L G t}s� U z-u-1 L, VALID / T6 f / DRIVEWAYS: <br /> (Applicant Name) STREET . 6 <br /> AREA QUAD <br /> "Li (��'��-'Nl.� �- C,t�trV�Gf✓ P�J< i3i,lJ�-,�1, SIS 1) TYPE <br /> (Mailing Address) FORMS Z <br /> NOTES <br /> 5AVV r-rAvN; (:�,A 41 q S'K ; <br /> (City,State,Zip Code) <br /> 2_4 Lf _ '5'Lt 41 -61J)00 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SSC �Lhi�� � T►���r�- ccYv'��2--i-,� �c.-�� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S tA side of ;w S Ay", N 1 y?-Q approximately 3�c C, dee t feet/mileyN 6st <br /> of 0t-VVLt��S '''o 4 VJ L V" ,by performing the following work.(description of work): <br /> :—� N S--(a ILL A_(%O N 0 IF- 'V C-W 0 Cvp ,,yka'oL.. AIV.)e r -e-o r 01°L-A c t;� �x�S F, V6,1- <br /> Work <br /> GfiWork will commence on or about '/i i z-0 13 for approximately 3i days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E:\PUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(01108) <br />